HomeMy WebLinkAboutSeptic Plan Submittal Form - Receipt - 218 LACY STREET 10/13/2020 TOWN OF NORTH ANDOVER
Community & Economic Development
HEALTH DEPARTMENT
120 Main Street
NORTH ANDOVER,MASSAC14USETTS 01845
978.688.9540—Phone
978.688.9542—FAX
E-MAIL:healthdept@northandoverma.gov
WEBSITE:htW://www.northandoverma.gov
SEPTIC PLAN SUBMITTAL
FORM RECEIVED }
Date of Submission: July 17, 2019 TOfNO� �
mpg
Site Location:218 Lacy Street
Engineer:John D. Sullivan III, PE
New Plans? Yes X $275/Plan Check#210411 (includes I"submission and one re-
review only)
Revised Plans?Yes $125/Plan Check#
Site Evaluation Forms Included? Yes x No
Local Upgrade Form Included? Yes No x
Telephone#:781-854-8644 Fax#:
E-mail:jacksu1153@comcast.net
Homeowner
Name:Troy and Heidi Moran
OFFICE USE ONLY
When the ission is complete (including check):
➢ 7� Date stamp plans and letter
➢ Complete and attach Receipt
➢ Copy File; Forward to Consultant
➢ Enter on Log Sheet and Database
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Town of North Andover
HEALTH DEPARTMENT
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CHECK DATE:
LOCATION:
H/O NAME: 1171/'0_4
CONTRACTOR NAME:
Type of Permit or License:(Check box)
❑ Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service-Type: $
❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage Practice. $
❑ Offal(Septic)Hauler $
❑ RecreationaI Camp $
❑ Sun tanning $
❑ Swimming Pool $
❑ Tobacco $
❑ Trash/Solid Waste Hauler $
❑ Well Construction $
SEPTIC Systems:
❑ Septic-Soil Testing $
j` Septic-Design Approval $
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $
❑ Title 5 Report $
❑ Other:(Indicate) $
ealth Agent Initials
White-Applicant Yellow-Health Pink-Treasurer